Confidential Reference Form:
Applicant's Name
*
First Name
Last Name
Your Name
*
First Name
Last Name
E-mail
*
What is your relationship to the applicant?
Teacher
Employer
Friend
Mentor
Family
Pastor
Other
How long have you known the applicant?
1 year or less
1 to 5 years
More than 5 years
Back
Next
Please mark the description that best fits the applicant.
If you cannot judge. Do not answer.
Fulfills Obligations
1
2
3
4
5
6
7
8
9
10
Rarely
Always
1 is Rarely, 10 is Always
Flexible
1
2
3
4
5
6
7
8
9
10
Set in their ways
Goes with the flow
1 is Set in their ways, 10 is Goes with the flow
Emotionally Balanced
1
2
3
4
5
6
7
8
9
10
Unpredictable
Very well balanced
1 is Unpredictable, 10 is Very well balanced
Response to Authority
1
2
3
4
5
6
7
8
9
10
Distate for correction
Easily teachable
1 is Distate for correction, 10 is Easily teachable
Trustworthy
1
2
3
4
5
6
7
8
9
10
Questionable at times
High integrity
1 is Questionable at times, 10 is High integrity
Relationships with Others
1
2
3
4
5
6
7
8
9
10
Tolerated by others
Sought by others
1 is Tolerated by others, 10 is Sought by others
Leadership
1
2
3
4
5
6
7
8
9
10
Needs direction
Takes initiative
1 is Needs direction, 10 is Takes initiative
Influence on others
1
2
3
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5
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8
9
10
Morale and morality decrease
Morale and morality improve
1 is Morale and morality decrease, 10 is Morale and morality improve
Temper Control
1
2
3
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5
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8
9
10
Can "lose it"
Composed through difficulties
1 is Can "lose it", 10 is Composed through difficulties
Communication
1
2
3
4
5
6
7
8
9
10
Tells it like it is
Strategic and thoughtful
1 is Tells it like it is, 10 is Strategic and thoughtful
Spiritual Maturity
1
2
3
4
5
6
7
8
9
10
Lacking or hidden
Evident or intentional
1 is Lacking or hidden, 10 is Evident or intentional
Back
Next
Does the applicant appear to you to have a growing relationship with Christ?
Yes
No
Unknown
Please explain:
Do you have any knowledge of this person ever being convicted of a crime, other than a minor traffic offence?
*
Yes
No
Please explain:
Do you have any knowledge of this person ever being charged with or convicted of a child or sexual abuse offence?
*
Yes
No
Please explain:
Is there any reason you are aware of that the applicant should not be allowed to work with children in a residential setting?
*
Yes
No
Please explain:
Do you expect the applicant's work to be:
1
2
3
4
5
6
7
8
9
10
Poor
Superior
1 is Poor, 10 is Superior
Please share any final thoughts you have regarding the applicant.
Submit Form
Pleasant Hill Outdoor Camp
4654 Pleasant Hill Rd. Perrysville, Ohio 44864
419.938.3715
www.phoc.org
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